Category : GM SC ST CAT-I Physically Challenged Others

Male Female
Name: ......ate o! "irth:....
Father#s Name:..
Academic Qualification:
Programme egree
o$tained
%ni&ersity 'eg(lar )
istance
S*eciali+ation , Mar-s o$tained
.ith Class
/ear o!
*assing
%G
PG
Others i! any

No. o! years o! e0*erience: Ind(stry: Teaching: 'esearch:
N(m$er o! 'esearch *a*ers: Patents: A.ards:
Topic of Research proposed:




Research Centre
1. 2T%-'C: .e*artment:....'ecogni+ed: /es No

3. 2T%-'4: e*artment:.....'ecogni+ed: /es No
5. 2T%-''C: Belgaum. e*artment...
A**lication and Processing Fee etails: .. !or `. 677)- No.:ra.n on "an-...date:.
Applicants Address for correspondence

VISVESVARAYA TECHNOLOGICAL UNIVERSITY,

BELGAUM, KARNATAKA
APPLICATION FOR FOR P!"# $%c$ &'ngg( B) R'%'ARC!
FOR T!' ACA"'IC )'AR *+,-.,/



'esearch Centre a**lied !or: 2T%-'C 2T%-'4 2T%-''C

Fac(lty A**lied !or : 8ngineering Architect(re Science Management St(dies
F(ll time Part time Programme A**lied !or: Ph.. M.Sc.98ngg:

.
Paste 9 do not *in :
*ass*ort si+e
*hotogra*h in this
s*ace and get it
attested $y Princi*al
) ;ead o! College )
%ni&ersity last
attended or a
Ga+etted O!!icer
.

.
P0one#Cell No.. email1id: ..
Information of the Supervisor
Name: ate o! "irth...
A!!iliation : e*artment:
esignationArea o! 'esearch
Academic Qualification:
Programme egree
o$tained
%ni&ersity 'eg(lar )
istance
S*eciali+ation , Mar-s o$tained
.ith Class
/ear o!
*assing
%G
PG
Ph..
Others i! any
No$ of Pu2lications in t0e preceding / 3ears:
Research papers: 1. National <o(rnal communicated: 1. National <o(rnal
3. International <o(rnal 1. 3. International <o(rnal
Conference: Technical Reports: Book: Patents: Awards:
No. of students Supervising:
%l$
No$
Name o! the
Candidate)s
Programme
Please tic- 9:
%ni&ersity Category
/ear o!
registration
S*eci!y
.hether acting
as S(*er&isor
or
Co S(*er&isor
Area o!
S*eciali+ation
=hether
Final Thesis
S($mitted
9/)N:
Ph.. M.Sc.
98ngg:
1
3
5
>
?
@
A
6
Total
Undertaking from the Supervisor
IB is a *ermanent !ac(lty )em*loyee .or-ing as . in the
e*artment o! . in the organisation .......and is aged
less than @? years as on the date o! admission noti!icationB here$y certi!y that the candidate Mr.)Mrs...
.registering !or ..... degree (nder 2T% is not my son)da(ghter)immediate $lood relati&e and the total n(m$er o!
candidates registered (nder me in 2T% and other %ni&ersities !or $oth Ph.. 4 M.Sc. 98ngg.: $y 'esearch ta-en together e0cl(ding *resently
a**lied candidates is 9in =ords: The in!ormation *ro&ided a$o&e is tr(e to the $est o! my -no.ledge.
"ate:
Place:
%ignature : 11111111111111111111111111111111111111111
For4arded 23 B...

"ate: %ignature of t0e Principal#"irector#!ead of t0e Researc0 Centre 4it0 %eal
Information of the Co-Supervisor( if applicale!
Name: .ate o! "irth...
A!!iliation: . .. e*artment:
esignationArea o! 'esearch
Academic Qualification:
Programme egree
o$tained
%ni&ersity 'eg(lar )
istance
S*eciali+ation , Mar-s o$tained
.ith Class
/ear o!
*assing
%G
PG
Ph..
Others i! any
No$ of Pu2lications in t0e preceding / 3ears:
Research papers: 1. National <o(rnal communicated: 1. National <o(rnal
3. International <o(rnal 1. 3. International <o(rnal
Conference: Technical Reports: Book: Patents: Awards:
No. of students Supervising:

%l$
No$
Name o! the
Candidate)s
Programme
Please tic- 9:
%ni&ersity Category
/ear o!
registration
S*eci!y
.hether
acting as
S(*er&isor or
Co S(*er&isor
Area o!
S*eciali+ation
=hether
Final
Thesis
S($mitted
9/)N:
Ph.. M.Sc.
98ngg:
1
3
5
>
?
@
A
6
Total
Undertaking from the Co-Supervisor
IB is a *ermanent !ac(lty )em*loyee .or-ing as . in the
e*artment o! . in the organisation .......and is aged
less than @? years as on the date o! admission noti!ication here$y certi!y that the candidate Mr.)Mrs...
.registering !or ..... degree (nder 2T% is not my son)da(ghter)immediate $lood relati&e and the total n(m$er o!
candidates registered (nder me in 2T% and other %ni&ersities !or $oth Ph.. 4 M.Sc. 98ngg.: $y 'esearch ta-en together e0cl(ding *resently
a**lied candidates is 9in =ords:. The in!ormation *ro&ided a$o&e is tr(e to the $est o! my -no.ledge.
"ate:
Place:
%ignature : 11111111111111111111111111111111111111111
For4arded 23 B...

"ate: %ignature of t0e Principal#"irector#!ead of t0e Researc0 Centre 4it0 %eal
5nderta6ing 23 %uper7isor # Co.%uper7isor 8&in case Co.%uper7isor is opted(
No O29ection Certificate of t0e Organisation
'mplo3ment Certificate of t0e %uper7isor
'mplo3ment Certificate of t0e Co.%uper7isor &in case Co.%uper7isor is opted(
%uper7isors Address for correspondence
I ) =e ha&e no o$Cection in g(iding the said candidate in the *ro*osed area o! research at the designated 'esearch Centre.
I! !or any reasonB mysel! )candidate change the 'esearch CentreB I ).e .ill in!orm the same to the %ni&ersity .itho(t
!ail.
%ignature of Co.Supervisor %ignature of t0e Supervisor
%ignature of t0e !ead of t0e Institution 40ere t0e researc0 4or6 is proposed::::::::::::::::$::

This is to certi!y that the Organisation has no o$Cection in recommending the candidat(re o! o(r
em*loyee!or carrying o(t research !or his)her Ph..) M.Sc. 98ngg.: $y research
at .... on *art
time ) !(ll time $asis. T0e information pro7ided 23 t0e candidate is found correct as per our records.
%ignature of t0e Principal#!ead 4it0 %eal$
This is to certi!y that r. *resently .or-ing in the ca*acity
o!in the e*artment o!... is a full time emplo3ee o!
o(r OrganisationB since..
Organisation: Seal and Signat(re o! the
;ead o! the Organisation
This is to certi!y that r *resently .or-ing in the ca*acity
o!in the e*artment o!... is a full time emplo3ee o!
o(r OrganisationB since..
Organisation: .. Seal and Signat(re o! the
;ead o! the Organisation
.
.

P0one No.. email1id: ..
Co.%uper7isors Address for correspondence
.
.

"nclose attested copies of the follo#ing$ efore sending the application :
1. Detailed Bio-data of the Candidate, Supervisor
(and Co-Supervisor, if applicable)
A. Any other additional Certificates supporting your claim
for benefits like
!edical Certificate for the degree of disability in
support of candidates claiming benefit
"est Score Card along #ith Admission ticket in
support of clearance of $%C&$%C-CS'( )(*
'n case candidate&Supervisors are possessing
degree from *oreign $niversities, "he
+,uivalence Certificate issued by the Association
of 'ndian $niversities( A'$)
-assport #ith .isa in the case of *oreign
candidates
3. $% and -% degree Certificates and !arks cards of the
Candidate
5. $%, -% and -hD Degree Certificates of the
Supervisor&Co-supervisor
>. Category certificate of candidates belonging to
SC&S"&Cat-'& and any other if applicable
?. Synopsis of the proposed research
@. Demand Draft of `/011 dra#n in favour of "he *inance
2fficer, ."$, Belgaum to#ards Application and
-rocessing fee
P0$"$#$%c$&'ngg(

Name o! the A**licant:
Name o! the S(*er&isor : .....
Name o! the Co-S(*er&isor:.
'esearch Centre92T%-'C)2T%-''C::...
Programme:..
Mo$ile No: Phone ..

Application No.

%&&'IC%TI(N )(R* )(R UNI+"RSIT, L';'L R'%'ARC! APTIT5"' T'%T &5LRAT(
Test Centre Code: "angalore "elga(m G(l$arga None
&rogramme Stream %pplied for:
1. Mechanical 8ngineering A. "io-Technology 15. Maths
3. Com*(ter Science 8ngineering 6. Polymer Science 1>. Physics.
5. 8lectrical 8ngineering D. Sil- Technology 1?. Chemistry
>. Ci&il 8ngineering 17. Te0tile 1@. Management St(dies
?. 8n&ironmental 8ngineering 11. Chemical 1A. Com*(ter A**lications
@ . Architect(re. 13. Geology 16. Ei$rary Science 1 1A.
Statistics 1D. Physical 8d(cation
'ducational Qualification 40ic0 ma6es 3ou eligi2le for t0e Programme
Program egree A.arded S*ecialisation Percentage o!
Mar-s)CGPA .ith
Class
S*eci!y 'eg(lar or istance
8d(cation
%G
PG
Nationalit3: Indian Others 9N'I)FN)PIO:: <ender: Male Female
Categor3: General SC ST Cat-1 O"C Any Other.
=0et0er P03sicall3 c0allenged /es No : I! /esB Nat(re o! disa$ility:....
%pecif3 t0e status of ;T5 TAT: Cleared in <(ly 3717 Cleared in <an 3711 Cleared in <(ly 3711
=rite the TAT Seat No.
National Test >ualified 4it0 7alid score
:::::::::::::::::::::::::::::::::$
Are 3ou a facult3 under QIP#FIP: /es No
Address for correspondence:
;I%;'%;ARA)A T'C!NOLO<ICAL 5NI;'R%IT)
?@nana sangamaA
Belgaum./B+ +,CD Earnata6aD India
Note:
1. This Form sho(ld $e !illed $y all the candidates irres*ecti&e o! their eligi$ility to $e e0em*ted !rom the %E'AT as
s(ch an e0em*tion is s($Cect to a thoro(gh scr(tiny o! s(**orting doc(ments satis!actorily *ro&ided $y the candidate
along .ith this A**lication
Seat No.:
For Office 5se onl3
Paste 9 do not *in :
*ass*ort si+e
*hotogra*h in this
s*ace and get it
attested $y
Princi*al ) ;ead o!
College ) %ni&ersity
last attended or a
Ga+etted O!!icer
To e filled - candidates
Name:
Address.

.......................................
Programme a**lied !or:
..
Candidate#s Signat(re
For those having
validity of VTU Tech.
Aptitude Test
ate o! %E'AT:
Test Centre:
'e*orting Time:
If 3ou possess ;T5 5LRAT Test 7alidit3B then *ro&ide Seat No :...
.eclaration - the Candidate
Visit www.vtu.ac.in for Recognized Research Centres, Fee Structure and Syllabus for %E'AT.
Exemption from ULRA Test
The following categories of candidates will be exempted from appearing at the ULRA Test:
(a) Faculty embers under !"# $ F"# and
(b) %andidates &ualified in U'% $ U'%(%)"R *RF+
I here$y ac-no.ledge that all the in!ormation gi&en
$y me are tr(e to the $est o! my -no.ledge. In the e&ent o! any in!ormation $eing !o(nd incorrect or
misleadingB my candidat(re shall $e lia$le to cancellation $y the %ni&ersity at any time and I shall not $e
entitled !or re!(nd o! any !ee *aid $y me to the %ni&ersity.
ate: Signat(re o! the Candidate